Common use of Preventive Care Services Clause in Contracts

Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0% - After deductible 40% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Pediatric clinic visits 0% - After deductible 40% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40% - After deductible Retail clinics 0% - After deductible 40% - After deductible Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. 0% - After deductible 40% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40% - After deductible Organ Transplants Organ transplant services 0% - After deductible 40% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible

Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection only, including administration. 0$0 20% - After deductible 40Diabetic Office Visits Podiatrist Services - First routine visit in a plan year $0 20% - After deductible Vision Care Services - first routine eye exam in a plan year that includes a retinal eye exam. $0 20% - After deductible Hospital based clinic visits 0% - After deductible 40% - After deductible Pediatric clinic visits 0% - After deductible 40$50 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. 0% - After deductible 40$30 20% - After deductible Retail clinics 0% - After deductible 40$30 20% - After deductible Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. 0% - After deductible 40$50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 0% - After deductible 40$30 20% - After deductible Organ Transplants Organ transplant services 0% - After deductible 4020% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible